MKSAP 19 Cardiology

Question 1

How to transition ACE/ARB to Entresto for patients with HFrEF?

Answer 1

If patient is on an ACE, requires transition period of 36 hours, if ARB none needed

Question 2

Why is a transition period needed for ACE, before changing to Entresto for patients with HFrEF?

Answer 2

Because of risk of angioedema

Question 3

When is digoxin helpful in patients with HFeF? How so?

Answer 3

When patients have a-fib as well. Usually can be used more if patients still have refractory symptoms of HFrEF. reduce the number of hospitalizations

Question 4

What is the significance of ivabradine in patients with HF? When is it recommended?

Answer 4

can reduce number of HF hospitalizations, can be given for patients <35 EF, NYHA II=IV, sinus HR >70, despite maximally tolerated BB

Question 5

Pt with gradual loss of stamina, and low energy, cannot run the usual 2 miles, prolonged recovery period. HR is 52, regular. Ambulatory 48 hour monitoring, shows HR of 72 during vigorous activity. What may be the problem, and what does it mean?

Answer 5

symptomatic bradycardia, needs pacemaker

Question 6

What are indications for a pacemaker?

Answer 6

symptomatic bradycardia without reversible cause; permanent atrial fibrillation with symptomatic bradycardia; alternating bundle branch block; and complete heart block, high-degree atrioventricular (AV) block, or Mobitz type 2 second-degree AV block, irrespective of symptoms.

Question 7

For patients with limb claudication, who already is receiving GDMT and already done an exercise program, but still experiencing limb claudication, what is next best step? What type of drug is it?

Answer 7

add cilostazol, it is a phosphodiesterase inhibitor with anti-platelet properties, and vasodilator properties

Question 8

Cilostazol is contraindicated in what patients?

Answer 8

patients with heart failure

Question 9

What is cilostazol’s side effects:

Answer 9

headache, diarrhea, dizziness, and palpitations.

Question 10

When is a good time to utilize cardiac CTA in acute chest pain?

Answer 10

For patients, who have a possible diagnosis of NSTEMI who have equivocal initial troponin levels, or a single troponin elevation without further symptoms of acute coronary syndrome, or patients who have ischemic symptoms that resolved hours before undergoing testing.

Question 10

Adenosine myocardial perfusion imaging is contracted in patients with ______.

Answer 10

Bronchospastic reactive airway disease.

Question 11

How would a ventricular septal defect mumur (small) sound?

Answer 11

Holosystolic murmur located lat left sternal border, that oblierates the S2.

Question 12

For a small VSD, does it need any intervention?

Answer 12

No, because they do not cause lefft heart enlargement of pulmonary hypertension and EKG and chest radiograph reveal normal findings. VSD is not indicated for patients with small left to right shunt and no chamber enlargement or valve disease, but periodic clinical evluation and imaging recommended. no activity restrictions

Question 13

How do patients with atrial septal defects present? Physical exam findings? small vs large shunt

Answer 13

Elevation in venous pressure, right ventricular lift, and fixed splitting of S2, a pulmonary mid-systolic flow murmur, and when there is a large shunt, a tricuspid diastolic flow rumble.

Question 14

50 patients of patients who have co-arctations will have ____

Answer 14

biscuspid valve

Question 15

Patients with aortic coarctation, physical exam findings:

Answer 15

upper extremity hypertension, radial artery to femoral artery pulse and blood pressure differentials, and systolic murmur over the left heart related to obstruction from coarctation

Question 16

What does the EKG demonstrate for patients with aortic coarctation:

Answer 16

left vetricular hypertrophy, and a typical chest radiograph which shows abnormal aortic contour and rib notching

Question 17

Continuous murmur heard beneath the left clavicle that envelops the S2

Answer 17

small patent ductus arterosus

Question 18

What are the indications for CABG? (not emergency)

Answer 18

high grade L main stem coronary artery stenosis, >70% signficiant stenosis of proximal LAD, with 2 or 3 vessel disease, symptomatic 2 vessel or 3 vessel disease, disabling angina despite maximal medical therapy, poor left ventricular function with myocardium that can return to function on revasculazation, post infarct agina.

Question 19

What are the indications for emergency CABG?

Answer 19

non-ST segment elevation myocardial infarction with ongoing ischemia that is unresponsive to medical therapy/ PCI, STEMI with inadequate response to all nonsurgical therapy, significant ongoing ischemia, traumatic complications, or threatened occlusion in STEMI, after failed PCI, or previous CABG

Question 20

Patient 70 yo M, worsening exertional dyspnea, Hx of bilateral carpal tunnel, elevated BNP, normal L ventricular cavity size, and moderate LV hypertrophy, and R ventricular hypertrophy, cavity size is normal. Estimate ventricular systolic pressure is 40 mm, decreased voltage on EKG: Consider: and what to obtain next? what would be seen in cardiac MRI?

Answer 20

Amyloidosis, cardiac MRI, diffuse late mid-myocardial gadolinium enhancement in a non-coronary distribution.

Question 21

Concerning amyloidosis, CMR imaging with gadolinium, is both highly ___ and ____ for cardiac amyloidosis, but does not distinguish between ___ and ____

Answer 21

sensitive and specific, cannot distinguish between AL (immunoglobulin light-chain) amyloidosis and ATTR amyloidosis

Question 22

Abnormal 99m-technetium pyrophosphate scan would confirm ______

Answer 22

ATTR amyloidosis without the need for biospy

Question 23

Diffuse LV hypertrophy, prominent St-T abnormalities, burning dysesthesias, childhood illness:

Answer 23

Fabry’s disease, diagnosis through genetic testing or an abnormal serum alpha galactosidase level

Question 24

What are the indications for aortic valve replacement in patients with severe aortic stenosis?

Answer 24

1. presence of symptoms, 2. left ventricular systolic dysfunction (EF <50%), in an asymptomatic patient or (3) a concomitant cardiac surgical procedure for other indications.

Question 25

When is transcatheter aortic valve implantation preferred over surgical aortic valve replacement?

Answer 25

IN patients over 80 years old or younger patients with a life expectancy less than 10 years. TAVI also recommended for symptomatic patients of any age with severe aortic stenosis and a high or prohibitive surgical risk if predicted postprocedure survival is more than 12 months with an acceptable quality of life. For patients who are 65 to 800 years old, either SAVR or TAVI is appropriate

Question 26

What are two reasons (secondary preventive reasons) patients should have an implantable cardioverter-defibrillator placement?

Answer 26

Patients with sustained ventricular arrhythmias (>30 seconds) or cardiac arrest without a reversible cause have a class 1 recommendation for secondary prevention with an implantable cardioverter-defibrillator.

Question 27

What are two reasons (secondary preventive reasons) patients should have an implantable cardioverter-defibrillator placement?

Question 28

21 yo F, cardiac arrest during cross county race. Echo reveals ormal left ventricular function and R ventricular dilation and dysfunction, LHC is normal. Suspicion for?

Answer 28

Arrhythmogenic right ventricular cardiomyopathy, an inherited “wear and tear” disorder affects R ventricular mainly but may be seen in the left. Cardiac MRI may assess myocardial infiltration, before iCD infiltration.

Question 29

For patients with contamitant cardiovasclar conditions and a -fib, what is preferred strategy for a -fib and a fib < 12 months?

Answer 29

rhythm control (antiarrhythmi drugs or ablation)

Question 30

In patients who are being treated for stable angina pectoris, what antiplatelet therapies to consider?

Answer 30

low dose asa vs plavix in asa intolerant patients

Question 31

Peripartum cardiomyopathy can happen ______ or ______

Answer 31

months after delivery or toward the end of pregnancy

Question 32

In patients with peripartum cardiomyopathy, who still hasn’t delivered, what medications to avoid?

Answer 32

ACE/ARB, spironolactone

Question 33

In patients after delivery, who develop chest pain, should think about:

Answer 33

Spontaneous coronary artery dissection, which happens during 1st month post partum.

Question 34

What is pulsus paradoxus?

Answer 34

when inspire, decrease in blood pressure by 10 mm Hg

Question 35

Pericardial Effusion, R-atrial mass contiguous with the lateral wall of the right atrium, in patient with non-productive cough, dyspnea, and constant CP, non smoker

Answer 35

cardiac angiosarcoma

Question 36

At time of diagnosis of cardiac angiosarcoma, metasis to the _____ is commonly present. Tx? Prog?

Answer 36

lungs, liver, lymphatic system, bone, adrenal glands, surgical resection, adjuvant chemo or radio, survival rates low

Question 37

Which is more likely to cause hyponatremia? loops or thiazides?

Answer 37

thiazides, because they work in the distal, vs loops which work in the proximal.

Question 38

HF with a warm and wet profile, on a beta blocker should _______ if BP is good, but if refractory to diuretics, should be _______

Answer 38

continue, but should half the dose if refractory

Question 39

For acute management of aortic dissection:

Answer 39

Rapid acting beta blockers, such as esmolol, to titrate HR <60, then can be replaced with metoprolol. If BP remains elevate, IV nitroprusside can be used to lower BP to lwest tolerable limit between 100 to 120.

Question 40

If patients with a type B aortic dissection, end up developing iether new onset abdominal pain, or limb ischemia, then

Answer 40

surgery, preferably with thoracic endovascular aortic repair

Question 41

When do PVCs require treatment? What is treatment?

Answer 41

When patient is symptomatic, bothersome or frequent (>10% of all beats), beta-blocker or calcium channel blocker

Question 42

Cardiac sarcoidosis may present with what kind of arrhy

Answer 42

ventricu

Question 43

For patients with asymptomatic premature ventricular contractions, the is treatment?

Answer 43

reassurance, unless high risk features (syncope, family history of premature sudden cardiac death, structural heart disease)

Question 44

Patient is 3 week history of SOB and intermittent fevers, s/p aortic valve transplant for AS 3 years ago, admitted 1 month for diverticulitis, treated with ABX, then developed intermittent fevers after. Suspcect what? and what should be done?

Answer 44

endocarditis, high risk patient, if TTE doesn’t show, get TEE

Question 45

if there are suspected paravalvular infections for patient that cannot be clearly delineated by echo int he setting of suspected paravalvular infections, what imaging modality is reasonable?

Answer 45

cardiac CT scan

Question 46

mptoms deFor patients with ACS, regardless of reperfusion or revasculziation strategy, what is recommended in addition to aspirin, statin, IV heparin, and metoprolol?

Answer 46

early plavix laoding

Question 47

For patients with NSTEMI ACS, when is urgent invasive treatment (within 2 hours ) needed?

Answer 47

hemodynamic instability, refractory chest pain, heart failure, or ventricular arrhythmias

Question 48

For patients with peripheral artery disease, to reduce cardiovascular risk, in adition to aspirin, and atorvastatin is _____

Answer 48

to add low dose Xalrato (2.5 BID), which reduces occurence of cardiovascular death, unless they have a high risk for bleeding.

Question 49

Candidates for cardiac transplantation?

Answer 49

severe heart failure symptoms, despite maximal medical therapy, are candidates for advanced treatment: generally younger than 65 to 70ss years with no medical contraindications (diabetes with end organ complications, malignancies within 5 years, irreversible kidney dysfunction with GFR < 30 or other chronic illnesses that will decrease survival) and have good social support and adherence

Question 50

If patient is not a heart transplant patient, may be a candidate for an _______. These are patients who _____

Answer 50

EF<25%, NYHA class IV despite maximally tolerated therapy, with either a high predicted 1 or 2 year mortality or inotrope dependecny, who still want aggressive restorative care. Some patients receive an LVAD before transplantation if they have acute decompensation.

Question 51

Mumur of HOCM?

Answer 51

rapidly peaking crescendo-decresndo mumur heard best along the left lower sternal border.

Question 52

Murmur of a restrictive membranous ventricular septal defect?

Answer 52

harsh pansystolic mumur present at the left lower steernal border, not changing with dynamic maneuvers.

Question 53

symptoms? murmur? of Sinus of Valsalva aneurysm of the right or non coronary cusp :

Answer 53

acute dyspnea and decompensation, because pressure within aorta is always higher than in the right heart, loud mumur is heard in both systole and distole

Question 54

Mechanism of SCAD or spontaneous coronary artery dissection?

Answer 54

development of a non traumatic and noniatrogenic intramural hematoma, with or without intimal dissection with luminal communication. The enlarging hematoma in the false lumen compresses the true lumen of the coronary artery and if combined with obstructing dissection, elads to chest pain, ischemia, or infarction. Indicative findings on coronary angiography, including multiple radiolucent lumens and periluminal contrast straining

Question 55

Coronary vasospasm can happen ____ OR

Answer 55

spontaneously or following use of illicit substances (methamphetamines, cocaine) or prescription drugs (5 FU, bromocriptine), EKG abnormalities can mimic STEMI, d diagnosis of exclusion, and involves coronary angiography. Administration of nitrates or calcium channel blockers during cardiac catherization may show coronary dilation, which may indicate a vasospastic vessel

Question 56

Young woman, CP, Cardiac MRI shows diffuse perfusion abnormalities, LHC is negative, suspect:

Answer 56

micovascular dysfunction.

Question 57

The microvasculature, accounts for approximately _____ of the coronary resistance in the absence of _______

Answer 57

70%, obstructive coronary artery disease.

Question 58

narrow complex tachy, most common? characteristics?

Answer 58

AVNRT, starts abruptly, easily terminated by vagal maneuvers, happens mostly in women. EKG reveals a pseudo R’ in V1 (retrograde P wave) after QRS complex.

Question 59

First line therapy for AVNRT?

Question 60

What is first line therapy for patients with congestive heart failure and secondary severe mitral regurgitation? What happens if still symptomatic?

Answer 60

GDMT, if still symptomatic, then transcatheter edge to edge repair, if anatomy unfaorvable, surgery. If going for CABG, then also repair this surgically

Question 61

What are indications for cardiac resynchronization therapy?

Answer 61

In patients with EF <35% and sinus rhythm, is indicated in patients with LBBB, NYHA II to IV HF symptoms, and QRS duration of 150 ms or longer despite GDMT. (only class I recommendation)

Question 62

In adults, when is closure of PDA even if tiny indicated?

Answer 62

if there is left sided caridac chamber enlargement, as long as pulmonary artery systolic pressure is <50% systemic, even in absence of symptoms, but can be done for selected cases 50-66%.

Question 63

For ABI index, what are the ranges of values, and what do you expect?

Answer 63

claudication expected for ABI 0.4-0.9. If less than 0.4, may have ischemic rest pain, ulceration, gangrene. greater than 1.4, very calcified, uninterpretable.

Question 64

57 yo F, STEMI, acute occluded LAD, but also finds 70% stenosis of right RCA. Approach?

Answer 64

Stent the culprit vessel, and do staged PCI 4-6 weeks later on occluded vessel. However, some selected hemodynamically stable patient with low complex anatomy may be stented at that time

Question 65

What finding on EKG suggests HOCM?

Answer 65

LVH findings, + marked q waves in V4-V6, I, and aVL

Question 66

What findings on EKG, that suggest certain conditions, can suggest higher chance of ventricular arrthymias?

Answer 66

HOCM, previous Q waves, prolonged QT

Question 67

First line treatment for a-flutter (1st line)

Answer 67

catheter ablation

Question 68

Is rate control preferred in atrial flutter?

Answer 68

No, very hard to control

Question 69

When would you recommend to start Zetia or PCSK9 for patient on GDMT for peripheral artery disease?

Answer 69

when LDL <70

Question 70

In patients with recurrent pericarditis, initially treated with colchicine and an NSAID, what else should be considered?

Answer 70

addition of a glucocorticoid agent

Question 71

In most patients with structural heart disease, 95% of patients who present with arrhythmias are _____

Answer 71

ventricular tachycardia

Question 72

Cannon a-waves in v tach could indicate:

Answer 72

Av dissociation

Question 73

In precordial leads for V tach:

Answer 73

concordant, other morphology than RBBB or LBBB, NW axis,

Question 74

What other types of beats can be suggestive of V tach:

Answer 74

fusion beats (supraventricular+ventricular beats) or capture beats (sinus conducted producing a normal sinus)

Question 75

What is the differential of wide complex tachycardia?

Answer 75

V tach, SVT with abberency, pre-excited tachycardia, ventricular paced rhythm,

Question 76

Is ivabradine useful for patients with HFrEF <30% with a-fib?

Answer 76

no, only for sinus

Question 77

if spironolactone patient cannot take for GDMT for HF, what is alternative?

Answer 77

eprelenone

Question 78

Patients who use tratuzumab, what kind of surveillance is needed? why?

Answer 78

echo, 3,6,9,12 months after initiation, looking for reduced LV EF, as it can cause reversible cardiotoxicity

Question 79

What is the next step after echo reveals a 5.5 cm abdominal anueyrsm?

Answer 79

Abdominal CTA

Question 80

How is severe mitral valve stenosis defined as?

Answer 80

Mitra area <1.5 cm^2 or less, mean mitral gradient of more than 5 to 10 mm Hg at a normal heart rate

Question 81

In the circumstance that patient’s presentation with mitra stenosis severity seems at odds with one another, the next step is:

Answer 81

exercise echo, or exercise during LHC, to further quantify

Question 82

Most common extrinsic cause of sinus bradycardia:

Answer 82

medicaions, (β-blockers, CCB, digoxin, amio) donepezil, neostigmine, pyridostigmine

Question 83

What are other potential intinsic causes of sinus bradycardia?

Answer 83

Pathologic sinus bradycardia is most commonly caused by sinus node dysfunction due to age-related myocardial fibrosis. Less commonly, sinus node dysfunction may result from right coronary ischemia, hypothyroidism, intracranial hypertension, postoperative scarring or fibrosis from cardiothoracic surgery, or infiltrative or inflammatory disorders (e.g., sarcoidosis)

Question 84

The treatment of hemodynamically unstable sinus bradycardia in patients with a pulse is ______. What are other alternatives?

Answer 84

intravenous atropine. Alternatives include: intravenous dopamine or epinephrine or transcutaneous pacing

Question 85

For patients with concern for acute limb ischemia, what is the best next step?

Answer 85

start IV anticoagulation, diagnostic angiography, then intervention

Question 86

What are the potential causes of acute limb ischemia?

Answer 86

Acute thrombosis of a lower extremity artery, stent, or bypass graft. Other causes include thromboembolism, vessel dissection (usually occurring periprocedurally), or trauma.

Question 87

For patients with PFO for stroke patients, what are criteria?

Answer 87

<60, stroke, unknown cause, also 60 or greater if risk factors for stoke elevated

Question 88

For patients with HOCM, when to get septal reduction therapy?

Answer 88

guideline-directed medical therapy but with New York Heart Association functional class III to IV heart failure symptoms or recurrent syncope believed to be related to left ventricular outflow tract (LVOT) obstruction and an LVOT gradient of 50 mm Hg (resting or provoked) or greater should be considered for septal reduction therapy.

Question 89

For HOCM, what pharmacological therapy is recommended?

Answer 89

Pharmacotherapy and lifestyle modification are appropriate initial choices for treatment of hypertrophic cardiomyopathy (HCM) with obstructive symptoms. Nonvasodilating β-blockers and/or nondihydropyridine calcium channel blockers (verapamil, diltiazem) are first-line choices. For patients with persistent symptoms, adding disopyramide, a class IA antiarrhythmic drug with potent negative inotropic activity, to one of the other drugs is a recommended option.

Question 90

What are the things you want to avoid for patients with inferior MI?

Answer 90

Nitrates, diuretics, opioid analgesic agents, calcium channel blockers, and β-blockers (metoprolol)

Question 91

In patients who have suspected severe aortic stenosis, but there is a discreptency between clinical presentation and echo findings, best next step?

Answer 91

LHC

Question 92

How would you define severe aortic stenosis?

Answer 92

Severe aortic stenosis is typically defined by a small valve area (≤1.0 cm2), high peak velocity (≥4 m/s), and/or high mean gradient (≥40 mm Hg).

Question 93

Can asymptomatic patients with aortic stenosis suspected to be severe, be given a trendmill stress test?

Answer 93

Yes, symptom limited.

Question 94

What is first line treatment for symptomatic PVC’s?

Answer 94

BB (propranolol) or if not tolerated, or with depression, can try non-dihydropyridine calcium channel blockers instead. If decreased EF, prefer BB

Question 95

What are secondary causes of PVC?

Answer 95

anemia, hyperthyroidism, pregnancy

Question 96

What is the role of ambulatory EKG monitoring for the patient with symptomatic PVC’s?

Answer 96

Ambulatory ECG monitoring can help clarify whether her PVCs are episodic and of low overall burden or if they persist throughout the day. Patients with PVCs that account for more than 10% to 15% of beats may be at risk for developing PVC-induced cardiomyopathy and subsequent heart failure, which is an additional reason to treat this patient’s symptomatic PVCs. If she develops cardiomyopathy, it may be reversible with more aggressive treatment of PVCs (e.g., catheter ablation).

Question 97

Palpitations that subside with exercise and at night, should make you suspect:

Answer 97

PVC’s

Question 98

Atrial septal defect closure is indicated in patients with

Answer 98

symptoms or evidence of right-sided cardiac chamber enlargement and without severe pulmonary hypertension.

Question 99

Contraindications to dobutamine echo stress?

Answer 99

if patient has LBBB, which can limit echo image interpretation. Resting wall motion abnormalities, or contraindications to using dobutamine. acute coronary syndromes; severe aortic stenosis; hypertrophic obstructive cardiomyopathy; and uncontrolled hypertension, arrhythmias, or heart failure.

Question 100

Preferred stress modality for patients with LBBB, and can exercise? cannot exercise?

Answer 100

LBBB limits interpretation for heart rate dependent stress modalities So vasodilator stress is preferred. With the exception of LBBB, exercise single-photon emission CT is recommended when baseline ECG findings are abnormal or when information on a particular area of myocardium at risk is needed. With LBBB, conduction delay in the septum may cause false-positive abnormalities; vasodilator stress can improve the accuracy of perfusion imaging.

Question 101

The diagnostic findings are consistent with constrictive pericarditis typically presents _________ with including _______

Answer 101

indolent, progressive signs and symptoms of right heart failure, fatigue and exertional dyspnea.

Question 102

What physical exam signs can be seen in constrictive pericarditis, describe them:

Answer 102

Kussmaul sign and pericardial knock, Kussmaul sign, typically when you breath in, you decrease the thoracic pressure, which decresaes jugular venous pressure. This results in the falling the the jugular pulse. However, if constrictive pericarditis, there is no fall in this pressure, and on PE it stays there the same. Pericardial knocking is when there is impaired diastolic filling, and it creates a high pitched diastolic murmur.

Question 103

What findings would you expect to see on constrictive pericarditis?

Answer 103

normal right and left ventricular size and systolic function despite prominent symptoms and findings suggestive of heart failure. Dilatation of the inferior vena cava reflects elevated right-sided filling (right atrial) pressure.

Question 104

What are common precipitants of constrictive pericarditis?

Answer 104

pericarditis, cardiac surgery, chest irradiation, connective tissue disorders, and uremia

Question 105

How to differentiate between constrictive pericarditis and restrictive cariomyopathy?

Answer 105

Doppler echocardiography and tissue Doppler velocity are required to differentiate constrictive pericarditis from restrictive cardiomyopathy

Question 106

Can you clinically differentiate between restrictive cardiomyopathy and constrictive pericarditis?

Answer 106

impossible. Restrictive cardiomyopathy is more likely in a patient with a predisposing systemic disease, such as diabetes mellitus or amyloidosis, Restrictive cardiomyopathy is not associated with a pericardial knock, but this finding is sometimes difficult to distinguish from an S3.

Question 107

Can pulsus paradoxes be present in constrictive percarditis? it is the most common PE finding?

Answer 107

Yes, and it is not, more associated with kassmaul’s

Question 108

Urgent or immediate diagnostic angiography with intent to perform revascularization is indicated in patients with non–ST-elevation acute coronary syndrome who have ___ or ____

Answer 108

refractory angina or unstable angina

Question 109

When is an aldosterone antagonist beneficial in patients with myocardial infarction?

Answer 109

therapeutic doses of ACE inhibitors and β-blockers and have a left ventricular ejection fraction of 40% or less and either diabetes mellitus or heart failure. This patient does not meet the criteria for eplerenone therapy.

Question 110

A 30-day event monitor is most appropriate for evaluating patients with

Answer 110

palpitations who have symptoms that occur less than daily but frequently over the course of a month.

Question 111

An implantable looping event recorder is most appropriate for

Answer 111

infrequent or highly symptomatic arrhythmias in which the symptoms might preclude a patient from activating the device, such as syncope.

Question 112

Takotsubo cardiomyopathy is a syndrome characterized by ___________–

Answer 112

transient regional systolic ventricular dysfunction mimicking myocardial infarction in the absence of angiographic evidence of obstructive coronary artery disease.

Question 113

How would Takotsubo present on Echo?

Answer 113

In most cases of takotsubo cardiomyopathy, the regional wall motion abnormality extends beyond the territory perfused by a single epicardial coronary artery

Question 114

How is severe mitral regurgitation defined?

Answer 114

severe mitral regurgitation, defined as an effective regurgitant orifice area of 0.4 cm2 or greater, a regurgitant volume of 60 mL or greater, or a vena contracta of 0.7 cm or greater. T

Question 115

For asymptomatic patients with chronic severe mitral regurgitation, what are the class 1 indications for repair?

Answer 115

Class 1 indications for intervention in asymptomatic patients include a left ventricular (LV) ejection fraction of 60% or less and/or an LV end-systolic dimension of 40 mm or greater

Question 116

For patients with severe mitral regurgitation, if patients has an inadequate TTE, what other imaging modalities can be pursued?

Answer 116

TEE or CMR

Question 117

In patients with prohibitive surgical risk, what is recommended for mitral valve surgery?

Answer 117

transcatheter mitral valve repair (transcatheter edge-to-edge repair [TEER]. also mitral valve anatomy is favorable for the repair procedure and the patient’s life expectancy is at least 1 year.

Question 118

Patient with recent pacemaker transplant, presents with 1-week history of redness at the site of his pacemaker, patient is afebrile, normal leukocyte count, normal temperature. What could it be, and best next step?

Answer 118

pacemaker extraction. may be infection of the pacemaker pocket

Question 119

Dual antiplatelet therapy for at least ____months may be reasonable following elective placement of a drug-eluting stent in some patients at high risk for bleeding.

Answer 119

3, may consider discontuing plavix

Question 120

What supports restrictive cardiomyopathy in patients (echo)

Answer 120

preserved EF, biventricular thickening, pulm HTN

Question 121

If refractory for restrictive cardiomyopathy, what is next best step?

Answer 121

transplant

Question 122

What is preferred anticoagulation for patient with mechanical valve? How about pregnant mothers 1st trimester? 2nd, 3rd?

Answer 122

warfarin is preferred through all trimesters, except for first when >5 mg/d. then can think about IV dose adjusted heparin

Question 123

A difference in arm pressures: arm systolic pressures of greater than 15 to 20 mm Hg suggests

Answer 123

subclavian or innominate artery stenosis,

Question 124

For patients with acute CHF, what drugs can be started immediately?

Answer 124

ACE inhibitors can be started immediately in patients with acute heart failure in the absence of hyperkalemia; the estimated glomerular filtration rate should be monitored during uptitration. Guidelines recommend reducing intravascular volume with a loop diuretic and initiating an ACE inhibitor; β-blockers may be cautiously introduced when the patient is closer to being euvolemic.

Question 125

How do patients with Brudaga Syndrome present?

Answer 125

Cardiovascular syncopal events often occur suddenly and usually without a significant prodrome, although chest pain and palpitations may be present.

Question 126

What are other cardiovascular causes of syncope?

Answer 126

Causes of cardiovascular syncope include cardiac arrhythmia; coronary artery disease; and structural and obstructive disease, including aortic and pulmonary valve stenosis, obstructive hypertrophic cardiomyopathy, aortic dissection, and cardiac tamponade.

Question 127

What is brudaga syndrome?

Answer 127

gada syndrome is the association of Brugada pattern with ventricular fibrillation, arrhythmogenic syncope, or cardiac arrest.

Question 128

When would you go for surgical intervention for valve for patient with IE?

Answer 128

heart failure, or IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions,

PUS RIVER
Prosthetic valve endocarditis (most cases)
Uncontrolled infection
Supporative local complications with conduction abnormalities
Resection of mycotic aneurysm
Ineffective antimicrobial therapy (eg Vs fungi)
Valvular damage (significant)
Embolization (repeated systemic)
Refractory congestive heart failure

Question 129

For patients with congenital heart disease, when is phlebotomy recommended?

Answer 129

Adaptive erythrocytosis is well tolerated in patients with cyanotic congenital heart disease, and therapeutic phlebotomy is not indicated until hemoglobin concentration is greater than 20 g/dL (200 g/L).

Question 130

For patients with congenital heart disease, and patient has iron deficiency, low long should iron therapy be continued in patient with erythrocytosis?

Answer 130

compensated erythrocytosis with stable hemoglobin levels. Iron deficiency and resultant microcytosis in these patients are often caused by inappropriate phlebotomy or blood loss, such as menorrhagia, as in this case. This patient’s baseline hemoglobin level was nearly 18 g/dL (180 g/L), and initial therapy should include oral iron therapy, which often causes a rapid increase in erythrocyte mass. When the hemoglobin level and hematocrit begin to increase in 7 to 10 days, iron therapy should be discontinued.

Question 131

How to tell difference between athlete’s heart and HOCM on echo?

Answer 131

symmetric wall thickness of 13 mm or less and normal diastolic filling favor the diagnosis of athlete heart over the diagnosis of hypertrophic cardiomyopathy.

Question 132

Cancer survivors who received chest radiotherapy are at risk for the late development of cardiovascular complications, including

Answer 132

pericardial constriction, valvular heart disease, restrictive cardiomyopathy, and coronary artery disease.

Question 133

For patients who underwent radiation therapy in the past, exertional SOB, what PE exam would you expect for patient with complication of restrictive cardiomyopathy?

Answer 133

ignificant pulmonary hypertension (loud S2 and eventually widely split S2), and tricuspid and mitral valve regurgitation are commonly present

Question 134

Patients with a cardiac myxoma may present with :

Answer 134

Patients with a myxoma may present with valvular occlusive symptoms, such as dyspnea and syncope; embolic phenomena, including stroke or transient ischemic events; and/or constitutional symptoms, such as fever, anorexia, and weight loss.

Question 135

When is surgery indicated for patient with myxoma?

Answer 135

In patients with atrial myxoma and a central nervous system embolic event,

Question 136

Symptomatic patients with transient heart block, including Mobitz type 1 heart block and complete heart block, after inferior myocardial infarction may be treated with

Answer 136

temporary pacing.

Question 137

The diagnosis of HFpEF should be suspected in patients who meet the following three criteria:

Answer 137

symptoms of heart failure, left ventricular (LV) ejection fraction of 50% or greater, and no other apparent cause of heart failure symptoms.

Question 138

echo findings supporting hfpef:

Answer 138

HFpEF include normal LV cavity size, increased LV wall thickness, left atrial enlargement, abnormal diastolic function, and elevated pulmonary artery systolic pressure (>35 mm Hg).

Question 139

Aortic repair surgery is recommended in pregnant patients who have Marfan’s syndrome when _______________________

Answer 139

before conception to reduce this risk in those with an ascending aortic diameter greater than 4.0 cm and who have risk factors for aortic dissection.

Question 140

For patients with V tach, what is the initial imaging study :

Answer 140

The initial evaluation of ventricular tachycardia focuses on the identification of reversible causes and includes echocardiography, cardiac magnetic resonance imaging, and exercise ECG.

If the patient has idiopathic VT, which is VT in the absence of structural heart disease, an implantable loop recorder (ILR) (Option D) may be appropriate. Idiopathic VT typically manifests as palpitations in the third to fifth decades of life, often triggered by stress, emotion, or sleeplessn

Question 141

For patients with symptomatic severe aortic stenosis, and echo reveals a low flow, low gradient severe aortic stenosis, what is best next step?

Answer 141

. The most appropriate next step in management is to confirm the diagnosis of severe aortic stenosis with low-dose dobutamine stress echocardiography. If dobutamine infusion results in an increase in stroke volume by at least 20%, severe aortic stenosis is diagnosed by an increase in peak velocity to 4.0 m/s or greater with the valve area remaining 1.0 cm2 or less. In patients with suspected low-flow, low-gradient severe aortic stenosis with normal or reduced left ventricular ejection fraction, measurement of aortic valve calcium score by CT is also reasonable to further define aortic stenosis severity.

Question 142

In patients undergoing cabg, with pmhx of newly symptomatic aortic stenosis, and ascending aortic aneurysm, what is decision?

Answer 142

replace aortic valve, and if >4.5 cm repair ascending aorta at same time

Question 143

diastolic murmur heard at the left sternal border that increases in intensity with inspiration, a parasternal lift, and a soft systoliout flow murmur. associated with

Answer 143

pulmonary regurgitation, Pulmonary regurgitation is the most common

Question 144

systolic or continuous murmur heard in the left infraclavicular region or over the back.
collateral intercostal vessels may also be audible and palpable over the chest wall,
n ejection click, a systolic murmur at the cardiac base, or, sometimes, an S4

Answer 144

aortic co-arctation, +bicuspid aortic valve,

Question 145

Which patients who have pericarditis requires hospitalization and monitoring?

Answer 145

Patients with pericarditis and high-risk features, including temperature higher than 38.0 °C (100.4 °F), subacute onset, a large pericardial effusion or tamponade at presentation, oral anticoagulation therapy, or lack of response to treatment, may require hospitalization

Question 146

When are glucocorticoids reserved for patients with pericarditis?

Answer 146

recurrent, incessant (>4-6 weeks’ duration), or chronic (>3 months’ duration) despite standard therapy; uremic pericarditis not responsive to intensive dialysis; contraindications to NSAID therapy; or autoimmune-mediated pericarditis. This patient has no indication for glucocorticoid therapy, either as an inpatient or outpatient

Question 147

coronary vasospasm occurs either spontaneously from _____ or _____

Answer 147

vasomotor dysfunction or after exposure to drugs (such as cocaine or chemotherapeutic agents) a

Question 148

What can treat coronary vasospasm:

Answer 148

Treatment with calcium channel blockade and/or nitrates

Question 149

For patients who has increasing frequent angina, and patient on BID isosobide mononitrate. And patient is on aspirin, metformin, liraglutide, atorvastatin, lisinopril, diltiazem, and isosorbide mononitrate. One month ago, coronary angiography was performed because of the occurrence of angina at lower levels of exertion. It showed diffuse coronary disease without lesions amenable to revascularization and preserved left ventricular function.

Answer 149

Change isosrbide mononitrate to once a day, because a nitrate-free interval of 8 to 12 hours daily is required to avoid nitrate tolerance

Question 150

When are calcium channel blockers recommended in stable angina?

Answer 150

symptomatic despite β-blocker therapy or have intolerance to β-blockers. This patient is already taking the nondihydropyridine calcium channel blocker diltiazem for blood pressure and rate control, and given his persistent hypertension (goal systolic blood pressure <130 mm Hg), it would be reasonable to increase diltiazem before adding a dihydropyridine calcium channel blocker, such as amlodipine (Option A), as long as the resting heart rate remains above 55/min

Question 151

Ibrutinib, a tyrosine kinase inhibitor, is associated with increased rates of ____

Answer 151

atrial fibrillation. brutinib, a tyrosine kinase inhibitor, is an effective treatment for chronic lymphocytic leukemia and various B-cell lymphomas. It has been reported to cause atrial fibrillation in up to 16% of patients, and this can be a therapy-limiting adverse effect.

Question 152

Patient with an ischemic stroke of unknown cause in whom external ambulatory ECG monitoring is inconclusive ________

Answer 152

implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF (class 2a recommendation).

Question 153

A patient is is on warfarin, , he has a normal hemoglobin level, no clinical evidence of overt bleeding, and a therapeutic INR. for patient with mechanical valve. should i stop or lower dose of warfarin?

Answer 153

No

Question 154

In patients with a bicuspid aortic valve, CT angiography or magnetic resonance angiography of the thoracic aorta is indicated

Answer 154

when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately with transthoracic echocardiography.

Question 155

In patients who are undergoing valve intervention (aortic) if low pretest probability of CAD =? if intermediate to high =?

Answer 155

CT angiography of the coronary arteries is recommended and can be performed at the same time as CT angiography of the aorta. In those with intermediate or high pretest probability of coronary disease, invasive coronary angiography is recommended to assess coronary anatomy and guide the need for and type of revascularization. However, assessment of the aorta should occur first to rule out aortic pathology, which may complicate cardiac catheterization (imaging)

Question 156

Chronic limb threatening ischemia is characterized by _____. Best managed by:

Answer 156

more than 2 weeks of ischemic rest pain, nonhealing wound/ulcers, or gangrene in one or both legs that is attributable to objectively proven peripheral artery disease.

Immediate invasive angiography with endovascular revascularization is often the most effective strategy to preserve tissue viability.

Question 157

When is a cardioverter-defibrillator is recommended for patients with hypertrophic cardiomyopathy ?

Answer 157

previous documented cardiac arrest or sustained ventricular tachycardia.

But can offer:
risk factors for sudden cardiac death (SCD), such as SCD attributable to HCM in a first-degree or close relative aged 50 years or younger, left ventricular (LV) hypertrophy of 30 mm or greater in any LV segment, syncope suspected to be arrhythmic in nature, LV apical aneurysm, and LV ejection fraction less than 50%,

Question 158

Among patients with atrial fibrillation who have undergone percutaneous coronary intervention for acute coronary syndrome, what is preferred?.

Answer 158

double therapy with clopidogrel or ticagrelor plus a direct oral anticoagulant is recommended over triple therapy with an oral anticoagulant, aspirin, and P2Y12 inhibitor to reduce the risk for bleeding

Question 159

When is IE prophylaxis considered?

Answer 159

1) a history of IE; (2) cardiac transplantation with valve regurgitation due to a structurally abnormal valve; (3) a prosthetic valve; (4) prosthetic material used for cardiac valve repair, including annuloplasty rings and clips; (5) left ventricular assist device; (6) unrepaired cyanotic congenital heart disease; (7) repaired congenital cyanotic heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device; (8) a defect that has been repaired (surgical or catheter based) with prosthetic material within the previous 6 months; and (9) surgical or transcatheter pulmonary artery valve or conduit placement, such as Melody valve and Contegra conduit.

Question 160

What is used for IE prophylaxis?

Answer 160

amoxicillin (2 g once orally 60 minutes before the cleaning) would be the most appropriate therapy. Azithromycin should be reserved for patients able to take oral antibiotics who have a penicillin allergy.

Question 161

When is aortic valve surgery indicated in patients with severe aortic regurgitation?

Answer 161

aortic valve surgery is indicated regardless of left ventricular systolic function.
In asymptomatic patients with chronic severe aortic regurgitation and left ventricular systolic dysfunction (ejection fraction ≤55%), aortic valve surgery is indicated.

Question 162

In asymptomatic patients with severe aortic regurgitation, but doesn’t fit criteria for surgery, what is best to do?

Answer 162

clinical examination and echocardiography in 6 to 12 months

Question 163

Flecainide is a class IC antiarrhythmic agent and, along with propafenone, is absolutely contraindicated in patients____

Answer 163

with ischemic heart disease, given the increased risk for ventricular arrhythmias in this population.

Question 164

elevated central venous pressure, a right ventricular lift, and fixed splitting of the S2. A large left-to-right shunt causes a pulmonary midsystolic flow murmur and a tricuspid diastolic flow rumble owing to increased flow.

Answer 164

atrial septal defect